Governments and funders have long made a habit of failing to deliver primary health care to the people who would get the most from it. In 1978, world public-health leaders and associated muckety-mucks gathered in Kazakhstan and produced the famous Declaration of Alma-Ata that proclaimed — in good faith, I think — we would achieve “primary health care for all” by 2000. Well, that didn’t happen, but the World Health Organization (WHO) reaffirmed the declaration in 2008. The Millennium Development Goals included primary care and the Sustainable Development Goals (SDGs) include it again — and as many as a billion people still don’t have it.

What’s up? Why the big fails? Over the years, I’ve noticed three things:

  1. Doctors like fancy tertiary hospitals, Big Aid likes infrastructure. Health ministries are run by doctors and need Big Aid, so fancy hospitals come first. Then the money runs out.
  2. It’s always been easier to mobilize resources around particular diseases and needs (HIV/AIDS, malaria, polio, vaccination) than for systems. As a result, programs deliver services through vertical one-issue silos that starve and even undermine primary care.
  3. There haven’t been a lot of scalable, high-performance primary health care models out there, and some of the big studies of community health workers have been disappointing.

Things are changing. At the top-down level, the Primary Health Care Performance Initiative launched by the Gates Foundation, WHO, and the World Bank in 2015 is just one (big) sign that Big Aid is waking up. From the bottom-up, there are a growing number of entrepreneurial organizations doing cool work in primary care space, much of it inspired by the work of Paul Farmer and Partners in Health. Those emerging organizations represent a really important role and a huge opportunity for private philanthropy.

Read the full article about the need for primary health care in developing nations at Stanford Social Innovation Review.